Citation Nr: 1631393 Decision Date: 08/05/16 Archive Date: 08/12/16 DOCKET NO. 07-24 832 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in North Little Rock, Arkansas THE ISSUES 1. Entitlement to an initial increased disability evaluation for the service-connected posttraumatic stress disorder (PTSD) in excess of 50 percent prior to August 5, 1993. 2. Entitlement to an increased disability evaluation for the service-connected posttraumatic stress disorder (PTSD) in excess of 70 percent beginning August 5, 1993. 3. Entitlement to special monthly compensation (SMC) under 38 U.S.C.A. § 1114(s). 4. Entitlement to a total disability rating based on individual unemployability (TDIU) due to the service-connected posttraumatic stress disorder (PTSD) prior to March 28, 1997. 5. Entitlement to an effective date earlier than September 7, 1995, for the grant of service connection for headaches. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD M. Hannan, Counsel INTRODUCTION The appellant Veteran was a member of the Arkansas Army National Guard from July 1987 to July 1993; she served on an initial period of active duty for training from August 13, 1987 to January 15, 1988. The appellant was subsequently called to active duty during Desert Storm, serving from December 1990 to May 1991, including in Southwest Asia. This case originally came before the Board of Veterans' Appeals (the Board) on appeal from rating decisions issued by the Department of Veterans Affairs (VA) Regional Office (RO) in North Little Rock, Arkansas and the Appeals Management Center (AMC) in Washington, D.C. dated in July 2004, and June 2010. The Board most recently remanded the case for additional development in July 2014. The case has now been returned to the Board for appellate review. The Veteran has appealed the initial rating that was assigned for the posttraumatic stress disorder (PTSD) after service connection was granted. She is, in effect, asking for a higher rating effective from the date service connection was granted (May 22, 1991). As such, the guidance of Fenderson v. West, 12 Vet. App. 119 (1999) is for application. In the July 2004 rating decision, an initial evaluation of 50 percent was assigned effective May 22, 1991, and a 70 percent disability rating was assigned effective from August 5, 1993 (the date of a VA examination); this created a staged rating. Because neither of the two assigned evaluations at issue represents the maximum rating available for a psychiatric disability, the appellant's claim remains in appellate status. AB v. Brown, 6 Vet. App. 35, 38 (1993). In addition, because a total disability rating based on individual unemployability (TDIU) is a part of a claim for a higher rating, the Board must adjudicate whether a TDIU is warranted due to the PTSD alone. Rice v. Shinseki, 22 Vet. App. 447 (2009). Although entitlement to TDIU was granted in the July 2004 rating decision, it was granted effective March 28, 1997, which is later than the appeal period in this case. As the appeal for entitlement to a TDIU has been ongoing since the Veteran filed her disagreement with the initial evaluation assigned for the PTSD disability, this matter has been characterized as entitlement to a TDIU prior to the date of award, as opposed to seeking an earlier effective date. Id. Furthermore, in light of the decisions of the United States Court of Appeals for Veterans Claims (Court) in Buie v. Shinseki, 24 Vet. App. 242, 250 (2011) and Bradley v. Peake, 22 Vet. App. 280 (2008), the Board must consider whether the appellant is entitled to special monthly compensation (SMC) pursuant to 38 U.S.C.A. § 1114(s). Thus, the issues on appeal are as listed on the title page. This appeal was processed using the VA paperless claims processing system. Accordingly, any future consideration of this appellant's case should take into consideration the existence of this electronic record. The issue of entitlement to an earlier effective date for the grant of service connection for headaches is addressed in the REMAND portion of the decision below and that issue is REMANDED to the AOJ. The issue of entitlement to an effective date earlier than August 31, 2004, for the grant of special monthly compensation (SMC) benefits has been raised by the Veteran as reflected in the record by a February 2016 VA Form 21-526 EZ, but has not been adjudicated by the Agency of Original Jurisdiction (AOJ). Therefore, the Board does not have jurisdiction over the SMC issue, and it is referred to the AOJ for appropriate action. 38 C.F.R. § 19.9(b) (2015). FINDINGS OF FACT 1. As of September 7, 1995, the appellant was assigned a combined 60 percent evaluation for headaches, costochondritis and joint pain. 2. The appellant was granted Social Security Administration disability benefits as of March 15, 1997; the award was based on her psychiatric symptoms. 3. Prior to March 15, 1997, the appellant's PTSD was manifested by sleep disturbances, bad dreams, some intrusive thoughts, crying spells, decreased energy, depressed mood, trouble concentrating, a poor appetite, decreased socialization, emotional numbing, irritability and anger, but she was able to work and attend school; the PTSD was productive of severe impairment of social and industrial adaptability but not virtual isolation in the community, or totally incapacitating symptoms or an inability to obtain or retain employment. 4. As of March 15, 1997, the appellant was unable to work due to the service-connected PTSD. 5. The disability picture caused by the appellant's PTSD disability is not so unusual as to render the application of the regular schedular rating provisions impractical. 6. The appellant graduated from high school and also has two years of college education with experience working as an office manager and nursing assistant. 7. The appellant's service-connected PTSD was not of such nature and severity as to prevent her from obtaining and retaining substantially gainful employment prior to March 15, 1997. CONCLUSIONS OF LAW 1. With resolution of reasonable doubt in the Veteran's favor, the criteria for an initial evaluation of 70 percent, but not more, have been met for her service-connected PTSD under the regulations in effect before November 7, 1996. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.2, 4.7, 4.10 (2015); 38 C.F.R. §§ 4.125, 4.129, 4.130, 4.132, Diagnostic Code 9411 (1996). 2. The criteria for an evaluation in excess of 70 percent for her service-connected PTSD were not met prior to March 15, 1997, under either the regulations in effect before November 7, 1996, or the regulations in effect as of that date. 38 U.S.C.A. § 1155, 5102, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.2, 4.7, 4.10, 4.126, 4.130, Diagnostic Code 9411 (2015); 38 C.F.R. §§ 4.125, 4.129, 4.130, 4.132, Diagnostic Code 9411 (1996). 3. With resolution of reasonable doubt in the Veteran's favor, the criteria for a 100 percent evaluation have been met for her for her service-connected PTSD since March 15, 1997, under the regulations in effect before November 7, 1996. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.2, 4.7, 4.10 (2015); 38 C.F.R. §§ 4.125, 4.129, 4.130, 4.132, Diagnostic Code 9411 (1996). 4. The criteria for special monthly compensation at the housebound rate were met as of March 15, 1997. 38 U.S.C.A. § 1114(s), 5103, 5103A, 5107(b) (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.350 (2015). 5. The criteria for a TDIU based solely on the service-connected PTSD were not met prior to March 15, 1997. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.340, 3.341, 4.16, 4.19 (2015). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The appellant contends that she is entitled to an evaluation in excess of the currently assigned ratings for her service-connected PTSD. She maintains that she has not been able to work due to her PTSD symptoms since her service separation in May 1991. I. Duty to Notify and Assist VA's duty to notify and assist claimants in substantiating their claims for VA benefits has been codified in pertinent part at 38 U.S.C.A. §§ 5103, 5103A, 5107, 5126; 38 C.F.R. §§ 3.102, 3.159, 3.326(a). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and her representative of any information, and any medical or lay evidence, that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Quartuccio v. Principi, 16 Vet. App. 183 (2002). In addition, the decision of the United States Court of Appeals for Veterans Claims (Court), in Dingess v. Nicholson, 19 Vet. App. 473 (2006), requires more extensive notice in claims for compensation, e.g., as to potential downstream issues such as disability rating and effective date. In a claim for increase, the requirement is generic notice, that is, the type of evidence needed to substantiate the claim, namely, evidence demonstrating a worsening or increase in severity of the disability and the effect that worsening has on employment, as well as general notice regarding how disability ratings and effective dates are assigned. Vazquez-Flores v. Shinseki, 580 F.3d 1270 (2009). A claim for a total disability rating based on individual unemployability (TDIU) due to service-connected disability is, in essence, a claim for an increased rating. See Rice v. Shinseki, 22 Vet. App. 447 (2009); Norris v. West, 12 Vet. App. 413, 420 (1999); Hurd v. West, 13 Vet. App. 449 (2000). The appellant's PTSD claim arises from her disagreement with the initial evaluation assigned following the grant of service connection. The Court has held that, in cases where service connection has been granted and an initial disability rating and effective date have been assigned, the typical service-connection claim has been more than substantiated - it has been proven, thereby rendering notice under 38 U.S.C.A. § 5103(a) no longer required because the purpose that the notice is intended to serve has been fulfilled. Dingess, 19 Vet. App. at 491. See also Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007). In addition, because entitlement to TDIU and SMC have already been granted, VA's notice obligations with respect to those issues are fully satisfied, and any defect in the notice is not prejudicial. Goodwin v. Peake, 22 Vet. App. 128, 137 (2008) (where a claim has been substantiated after the enactment of the VCAA, the appellant bears the burden of demonstrating any prejudice from defective VCAA notice with respect to any downstream elements). Furthermore, to whatever extent the decision of the Court in Dingess requires more extensive notice in claims for compensation, e.g., as to potential downstream issues such as disability rating and effective date, the Board finds no prejudice to the Veteran in proceeding with the present decision. Letters to the appellant from VA, dated in July 2006, and July 2012, contained the information required by Dingess. VA must also make reasonable efforts to assist the claimant in obtaining evidence necessary to substantiate the claim for the benefit sought, unless no reasonable possibility exists that such assistance would aid in substantiating the claim. 38 U.S.C.A. § 5103A(a); 38 C.F.R. § 3.159(c), (d). Here, VA treatment records have been associated with the claims file and the appellant was afforded VA mental health examinations in September 1991, August 1993, November 1996, February 1997, October 2003, August 2006, March 2011, July 2012, and June 2015. Social Security Administration (SSA) records have been obtained and associated with the evidence of record. A medical opinion is adequate when it is based upon consideration of a veteran's prior medical history and examinations and also describes the disability in sufficient detail so that the Board's "evaluation of the claimed disability will be a fully informed one." Barr v. Nicholson, 21 Vet. App. 303, 311 (2007) (quoting Green v. Derwinski, 1 Vet. App. 121, 124 (1991)). The VA mental health examinations were conducted by medical professionals, and the associated reports reflect review of the appellant's psychiatric history. The examinations included reports of the appellant's symptoms for the PTSD disability and demonstrated objective evaluations. The VA examiners were able to assess and record the condition of the appellant's PTSD. The Board finds that the VA mental health examination reports are sufficiently detailed with recorded history, impact on employment and daily life, and clinical findings. In addition, it is not shown that any examination report was in any way incorrectly prepared or that any VA examiner failed to address the applicable schedular criteria. Therefore, the Board concludes that the appellant was afforded an adequate examination. Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). A remand from the Board or from the Court confers upon a veteran the right to substantial, but not strict, compliance with that order. D'Aries v. Peake, 22 Vet. App. 97, 105 (2008). In this case, pursuant to the Board remand issued in July 2014, the appellant was afforded a VA mental health examination. In addition, VA treatment records were obtained and added to the evidence of record. Therefore, substantial compliance has been achieved. In view of the foregoing, the Board finds that all notification and development actions needed to render a decision on the appellant's claims have been accomplished. II. The Merits of the Claims In adjudicating a claim, the Board determines whether (1) the weight of the evidence supports the claim or, (2) whether the weight of the "positive" evidence in favor of the claim is in relative balance with the weight of the "negative" evidence against the claim. The appellant prevails in either event. However, if the weight of the evidence is against the appellant's claim, the claim must be denied. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). A. Increased initial rating The law provides that disability evaluations are determined by the application of a schedule of ratings that is based upon an average impairment of earning capacity. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. Separate diagnostic codes identify the various disabilities. Where there is a reasonable doubt as to the degree of disability, such doubt will be resolved in favor of the claimant. 38 C.F.R. §§ 3.102, 4.3, 4.7. In addition, the Board will consider the potential application of the various other provisions of 38 C.F.R., Parts 3 and 4, whether they were raised by the appellant or not, and the entire history of the veteran's disability in reaching its decision, as required by Schafrath v. Derwinski, 1 Vet. App. 589 (1991). In the evaluation of service-connected disabilities, the entire recorded history, including medical and industrial history, is considered so that a report of a rating examination, and the evidence as a whole, may yield a current rating which accurately reflects all elements of disability, including the effects on ordinary activity. 38 C.F.R. §§ 4.1, 4.2, 4.10, 4.41. In this case the evidence reviewed includes the appellant's VA treatment records dated between 1992 and 2015; the reports of the VA mental health examinations conducted in September 1991, August 1993, November 1996, February 1997, October 2003, August 2006, March 2011, July 2012, and June 2015; Social Security Administration (SSA) records; testimony presented by the appellant during various personal hearings conducted at the RO; and written statements submitted by the appellant, her representative and various third parties. In general, when an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). However, staged ratings are appropriate in any increased-rating claim in which distinct time periods with different ratable symptoms can be identified. Hart v. Mansfield, 21 Vet. App. 505 (2007). Where there is a question as to which of two disability evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Lay assertions may serve to support a claim by supporting the occurrence of lay-observable events or the presence of symptoms of disability subject to lay observation. 38 U.S.C.A. § 1153(a); 38 C.F.R. § 3.303(a); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); see Buchanan v. Nicholson, 451 F.3d 1331, 1336 (Fed. Cir. 2006) (addressing lay evidence as potentially competent to support presence of disability even where not corroborated by contemporaneous medical evidence). In this case, there is no dispute that appellant is competent to report her PTSD symptoms because she has personal knowledge as it comes to her through her senses. See Layno v. Brown, 6 Vet. App. 465, 470 (1994). In any case, when a condition may be diagnosed by its unique and readily identifiable features, the presence of the disorder is not a determination "medical in nature" and is capable of lay observation. See Jandreau v. Nicholson, supra, at 1377 n.4 ("Sometimes the layperson will be competent to identify the condition where the condition is simple, for example a broken leg, and sometimes not, for example, a form of cancer."). In such cases, the Board is within its province to weigh that testimony and to make a credibility determination. The Court has stated that where the law or regulation changes during the pendency of a case, the version most favorable to the veteran will generally be applied. See West v. Brown, 7 Vet. App. 70 (1994); Hayes v. Brown, 5 Vet. App. 60 (1993); Karnas v. Derwinski, 1 Vet. App. 308 (1991). VA's Schedule for Rating Disabilities, 38 U.S.C.A. § 1155; 38 C.F.R. § 4.132, provides a general rating formula for psychoneurotic disorders, based upon the degree of incapacity or impairment and these regulations were amended, effective November 7, 1996. See 61 Fed. Reg. 52,695-702 (Oct. 8, 1996) (codified at 38 C.F.R. §§ 4.125-130 (1999)). In this case, the issue of entitlement to an increased rating for PTSD is initially considered only under the old regulatory criteria since the period of May 22, 1991 to August 5, 1993, entirely predates the effective date of the change in regulation. As of November 7, 1996, either the previous or the current rating criteria may apply, whichever are most favorable to the appellant, for her service-connected psychiatric disability. The appellant must be afforded review of the applicable rating for her psychiatric disability for all applicable periods, under both the old and new criteria. Current VA regulations require evaluation of mental disorders using the fifth edition of the AMERICAN PSYCHIATRIC ASSOCIATION 'S DIAGNOSTIC AND STATISTICAL MANUAL FOR MENTAL DISORDERS (DSM-5). 38 C.F.R. §§ 4.125, 4.126. An interim final rule was issued on August 4, 2014, that replaced the fourth edition of the AMERICAN PSYCHIATRIC ASSOCIATION'S DIAGNOSTIC AND STATISTICAL MANUAL FOR MENTAL DISORDERS (DSM-IV) with the DSM-5. However, the provisions of the interim final rule apply to all applications for benefits that are received by VA or that are pending before the agency of original jurisdiction on or after August 4, 2014. Jurisdiction over the present appeal was first conferred to the Board in August 2007. The basis of disability evaluations is the ability of the body as a whole, or of the psyche, or of a system or organ of the body to function under the ordinary conditions of daily life including employment. 38 C.F.R. § 4.10. PTSD, under the regulations in effect prior to November 7, 1996, was evaluated under Diagnostic Codes 9411. 38 C.F.R. Part 4, § 4.132 (1996). The initial 50 percent rating assigned by the RO contemplated considerable impairment of the ability to establish or maintain effective or favorable relationships with people; and by reason of psychoneurotic symptoms, the reliability, flexibility and efficiency levels were so reduced as to result in considerable industrial impairment. 38 C.F.R. § 4.132, Diagnostic Code 9411 (1996). Diagnostic Code 9411 also provided that, when the ability to establish and maintain effective or favorable relationships with people was severely impaired and the psychoneurotic symptoms were of such severity and persistence that there was severe impairment of the ability to obtain or retain employment, a rating of 70 percent was provided. Id. A 100 percent evaluation required that attitudes of all contacts except the most intimate be so adversely affected as to result in virtual isolation in the community and there be totally incapacitating psychoneurotic symptoms bordering on gross repudiation of reality with disturbed thought or behavioral processes (such as fantasy, confusion, panic, and explosions of aggressive energy) associated with almost all daily activities resulting in a profound retreat from mature behavior or that the individual was demonstrably unable to obtain or retain employment. Id. Pursuant to the amended regulations in effect as of November 7, 1996 up to the present, a 70 percent rating is assigned for occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting); inability to establish and maintain effective relationships. 38 C.F.R. § 4.130, Diagnostic Code 9411. Total occupational and social impairment, due to such symptoms as gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name, will be rated as 100 percent disabling. Id. Ratings are assigned according to the manifestation of particular symptoms. However, the use of the term "such as" in 38 C.F.R. § 4.130 demonstrates that the symptoms after that phrase are not intended to constitute an exhaustive list, but rather are to serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating. Mauerhan v. Principi, 16 Vet. App. 436 (2002). Further, in determining the appropriate disability rating, the Board must consider whether the case should be referred for extra-schedular consideration pursuant to 38 38 C.F.R. § 3.321(b)(1). See Thun v. Peake, 22 Vet. App. 111, 115-16 (2008). As indicated in Carpenter v. Brown, 8 Vet. App. 240, 242 (1995), the GAF is a scale reflecting the psychological, social and occupational functioning on a hypothetical continuum of mental health - illness, and a 51-60 rating indicates moderate difficulty in social, occupational or school functioning. The DSM-IV describes a GAF score of 51 to 60 as reflecting a moderate level of impairment, e.g., flattened affect, circumstantial speech, occasional panic attacks, or moderate difficulty in social, occupational or school functioning, e.g., having few friends or having conflicts with peers or co-workers. See 38 C.F.R. § 4.130. See also Cathell v. Brown, 8 Vet. App. 539 (1996); and Richard v. Brown, 9 Vet. App. 266, 267 (1996), wherein the Court stated that a "GAF of 50 is defined as 'Serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting) OR any serious impairment in social, occupational, or school functioning (e.g., no friends, unable to keep a job).'" Between December 1992 and July 1997, the appellant's GAF scores generally ranged from 50 to 60. The DSM-5 does not use GAF scores. Review of the evidence of record reveals that the appellant underwent a VA mental health examination in September 1991. She reported experiencing insomnia, bad dreams, a poor appetite, crying spells, not liking being in a crowd or around people, emotional numbing and intrusive thoughts. She said that she was working two days per week as a nursing assistant and that she was going to college. The appellant reported conflict with her brother. On mental status examination, she had a depressed mood. Memory was good in the interview, but the appellant thought that it was not as good as it was before service. The appellant was described as alert and oriented. The examination found no hallucinations or delusions. He noted depression and anxiety. Judgment was good. There was no suicidal ideation. In November 1992, the appellant was admitted to a VA hospital for complaints relating to headaches. While there, she was referred for a psychiatric consultation. She displayed no unusual psychomotor activity. Her affect was full range and her thoughts were logical and goal directed. There were no hallucinations, delusions or paranoia. Her memory (short-term and long-term) was intact and her judgment was good. The appellant reported that she was taking college courses and that she worked 15 hours per week. She stated that she had a good relationship with her mother, with her brothers and with her boyfriend. The mental health intake note reflects a diagnosis of a moderate major depressive episode; a GAF score of 60 (current and last year) was assigned. The appellant underwent another VA psychiatric examination in August 1993; the examiner reviewed the claims file. The appellant appeared underactive. She continued to work 16 hours per week and was taking college courses. She reported spending a lot of time in bed and having crying spells and she said that she did not socialize much. She reported poor sleep, nightmares and a poor appetite. The appellant also stated that she couldn't concentrate and felt that her memory was bad. On mental status examination, her mood indicated that she stayed depressed all the time. Her speech was coherent and relevant. She said that she didn't think about the future anymore. Thought processes were normal. The appellant was oriented times three. There were no hallucinations or delusions. She reported some suicidal and homicidal feelings but no actions. Psychological testing indicated that the appellant had made a deliberate and conscious attempt to exaggerate the extent of her psychiatric symptomatology; the test results were therefore found to be invalid. The appellant was hospitalized in a VA facility for depression for three days in January 1994. She complained of being sad all the time and claimed to be constantly tired. She reported a decreased appetite, crying every day secondary to worry, increased nervousness when meeting people, feeling scared for no reason and losing her temper. She did not have visual hallucinations and did not hear true voices. She denied active suicidal ideation or intention. No suicide attempt was noted. The appellant talked about hitting her boyfriend. On mental status examination, psychomotor activity was decreased overall. Mood appeared moderately depressed. The appellant was alert and oriented times three. There was no loosening of associations and there were no misperceptions or delusions. The appellant underwent psychological testing, but this was determined to yield invalid results. A provisional diagnosis was given and the appellant was assigned a GAF score of 55. A November 1995 VA social work note indicates that the appellant was complaining of increased depression and anxiety. She was noted to be alert and oriented times three; her mood was mildly depressed/anxious. There was no evidence of psychotic process. The appellant reported having negative thoughts, crying much of the time and having excessive worry about the future. She reported that she was getting married later that month. She denied having suicidal thoughts. A March 1996 VA social work note indicated that the appellant had an anxious and depressed mood. She reported hitting her husband with her fist. The appellant was noted to have poor self-esteem and to have a lot of anxiety about life. She felt that she did not do well in school but the social worker noted that her grades did not reflect this. There was no suicidal or homicidal thinking. A May 1996 VA mental hygiene clinic note indicates that the appellant reported episodes of uncontrolled anger in which she would blow up at her husband and hit and scratch him. She reported decreased motivation, missing school, frequently feeling angry or sad, being unable to handle minor stress and having decreased concentration and memory. On mental status examination, her mood was neutral. She was alert and oriented times three. Insight and judgment were fair. The appellant underwent another VA psychiatric examination in November 1996. She said that it seemed that she cried all the time and seemed sad and depressed all the time. She reported losing weight and sleeping excessively. She also reported some difficulty concentrating and said that she felt very depressed. The appellant reported some suicidal ideation but denied any intent. She said that she would sometimes blow up at her husband. She felt that she had a great deal of difficulty controlling her emotions. On mental status examination, the predominant mood was one of depression. The appellant's thought processes and associations were logical and tight. No gross impairment of memory was observed. Hallucinations were not complained of and no delusional material was noted. The examiner rendered a diagnosis of dysthymic disorder and assigned a GAF score of 55. The appellant underwent a VA neurology examination in December 1996. She reported working one day per week as a health care aide. She complained of memory loss and trouble concentrating. The appellant underwent another VA psychiatric examination in February 1997; the examiner reviewed the claims file. The appellant reported staying sad and depressed and doing a lot of crying. She said she could not work a fulltime job because of bad headaches. She also said that she had dropped out of nursing school. She reported having trouble falling asleep and feeling tired all the time. She also reported significant anhedonia. The appellant reported some suicidal ideation, but denied any plans or intent. She said she had a great deal of anger and would just explode for no reason. She said that she had significant marital problems. On mental status examination, the predominant mood was one of depression. Eye contact was minimal. The appellant's thought processes and associations were logical and tight. There was no confusion. No gross impairment of memory was observed. The appellant was oriented times three. Hallucinations were not complained of and no delusional material was noted. The examiner rendered a diagnosis of dysthymic disorder and assigned a GAF score of 55. In July 1997, the appellant was admitted to a VA facility for two days for treatment of depression. The Axis I diagnosis was manic depressive disorder, single episode, severe. She was admitted after reported increased depression, thoughts of self harm and violent behavior. The appellant gave a history of sudden intermittent violent behavior that would manifest itself without provocation. The appellant reported being separated from her husband and living with her mother. She said that she was unable to be employed due to her illness. The appellant denied current thoughts of self-harm and denied thoughts of harm to others. She was oriented times three. A GAF score of 35-40 was assigned on admission and a GAF score of 50 was assigned on discharge. The appellant underwent a psychological evaluation for SSA purposes in October 1997. She drove unaccompanied to the examination. She reported working with a home care facility one or two days per week from 1991 to 1994. Between 1994 and 1995, she worked fulltime in an outpatient drug rehabilitation center. The examiner rendered a diagnosis of major depressive disorder, severe with psychotic features. The examiner also rendered a diagnosis of borderline personality disorder. A December 1997 SSA psychiatric review form indicates that the appellant exhibited anhedonia; appetite disturbance; sleep disturbance; decreased energy; feelings of guilt or worthlessness; difficulty concentrating or thinking; hallucinations, delusions or paranoid thinking; seclusiveness or autistic thinking; pathologically inappropriate suspiciousness or hostility; persistent disturbances of mood or affect; pathological dependence, passivity, or aggressivity; and intense unstable interpersonal relationships and impulsive and damaging behavior. She was described as not having thoughts of suicide. The appellant was also described as having moderate restrictions in her activities of daily living; marked difficulties in maintaining social functioning; frequent deficiencies of concentration, persistence or pace; and repeated episodes of deterioration or decompensation in work or work-like settings. An administrative law judge (ALJ) from SSA issued a decision, in December 1998, in which the appellant was found to be disabled by reason of an inability to engage in substantial gainful activity (SGA). The appellant was determined to be disabled for SSA purposes on March 15, 1997; the appellant was described as not having engaged in SGA since that date due to her psychiatric symptomatology. The appellant was initially assigned a 50 percent evaluation for her service-connected PTSD, effective in May 1991. As previously noted, under the old PTSD rating criteria that was in effect prior to the November 1996 regulation changes, the next higher evaluation of 70 percent required severe impairment in the ability to establish or maintain effective and wholesome relationships with people and psychoneurotic symptoms resulting in such reductions in initiative, flexibility, efficiency, and reliability levels as to produce severe industrial impairment. 38 C.F.R. Part 4, Diagnostic Code 9411 (1996). The General Rating Formula for Psychoneurotic Disorder as in effect prior to November 7, 1996, provided that social impairment per se would not be used as the sole basis for any specific percentage evaluation, but was of value only in substantiating the degree of disability based on all of the findings. 38 C.F.R. § 4.132, Note (1) (1996). The Court has recognized, however, that, with regard to the 70 and 100 percent disability ratings, these two considerations (social inadaptability and industrial inadaptability) constituted separate, independent bases for granting the rating. See Dodd v. Nicholson, 21 Vet. App. 411 (2006); see also Johnson v. Brown, 7 Vet. App. 95, 99 (1994) (holding that each criterion in Diagnostic Code 9411 is an independent basis for granting a 100 percent rating); see also Diorio v. Nicholson, 20 Vet. App. 193, 198 (2006) (holding that the Diagnostic Code 9411 criteria for a 70 percent rating are also separate, independent bases for rating purposes). A veteran is entitled to a 70 percent rating for PTSD if the "[a]bility to establish and maintain effective or favorable relationships with people is severely impaired," or "[t]he psychoneurotic symptoms are of such severity and persistence that there is severe impairment in the ability to obtain or retain employment." 38 C.F.R. § 4.132, Diagnostic Code 9411. The terms "considerable" and "severe" in 38 C.F.R. § 4.132 were quantitative in nature. Hood v. Brown, 4 Vet. App. 301 (1993). "Considerable" was to be construed as rather large in extent or degree. VAOPGCPREC 9-93 (1993), 59 Fed. Reg. 4752 (1994). The Board is bound by that interpretation of the term "considerable." 38 U.S.C.A. § 7104(c) (West 2014). In addition, 38 C.F.R. § 4.16(c) stated that in cases where a mental disorder assigned a 70 percent evaluation was the only compensable service-connected disability, and such mental disorder precluded a veteran from securing or following a substantially gainful occupation, in such cases, the mental disorder shall be assigned a 100 percent schedular evaluation under the appropriate diagnostic code. See 54 Fed. Reg. 4280-01 (Jan. 30, 1989). This section was repealed when the revised criteria for rating psychiatric disabilities became effective on November 7, 1996. 61 Fed. Reg. 52695 (Oct. 8, 1996). However, the appellant was service-connected for another disability (costochondritis) rated as 10 percent, effective May 22, 1991; accordingly, 38 C.F.R. § 4.16(c) does not apply as there was another compensable service-connected disability besides the PTSD from May 22, 1991 onward. The Court, in Johnson v. Brown, 7 Vet. App. 95 (1994), held that the criteria for a 100 percent rating in 38 C.F.R. § 4.132, Diagnostic Code 9411, are each an independent basis for granting a 100 percent rating. Therefore, if a veteran's PTSD results in either (1) ". . . virtual isolation in the community," (2) "[t]otally incapacitating psychoneurotic symptoms . . .," or (3) "[demonstrable inability] to obtain or retain employment," a 100 percent schedular rating would be applicable. See 38 C.F.R. § 4.132, General Rating Formula for Psychoneurotic Disorders. The evidence reported above reflects that the Veteran exhibited some psychiatric symptoms that were considerable in severity and some psychiatric symptoms that were severe between May 22, 1991 and March 14, 1997. While further medical inquiry could be conducted with a view towards resolution of the question of whether all of the appellant's psychiatric symptoms can be attributed to her PTSD alone, it is doubtful that such research would assist the Board in its inquiry. See e.g., Mittleider v. West, 11 Vet. App. 181, 182 (1998) (Observing that when it is not possible to separate the effects of a service-connected condition and a non-service-connected condition, the provisions of 38 C.F.R. § 3.102 mandates that reasonable doubt on any issue was to be resolved in the veteran's favor, and that all signs and symptoms be attributed to the service-connected condition). Affording the Veteran the benefit of the doubt on the question of the severity of the PTSD disability, the Board finds that there is enough evidence to support an initial schedular evaluation of 70 percent for the appellant's PTSD. The medical evidence shows that the appellant's PTSD symptomatology was severe enough to result in social isolation, anxiety, depressed mood, chronic sleep impairment, difficulty controlling mood/irritability and problems with interpersonal relationships. The appellant has reported problems with forgetfulness and lack of concentration, explosive anger, anxiety and irritability, occasional physical violence and some vague suicidal/homicidal ideation without any plans or actions. On the other hand, she had never had any delusions or psychotic symptoms and she was never in virtual isolation. There are findings of record that indicate the appellant had moderate depression and anxiety that affected her ability to function effectively and that she had social avoidance. However, the Veteran is not entitled to an evaluation in excess of a 70 percent schedular rating at any time between May 21, 1991 and March 14, 1997, under the regulations in effect both before November 7, 1996, and as of November 7, 1996. In regard to the regulation in effect prior to November 7, 1996, the evidence of record does not indicate that the appellant suffered from virtual isolation in the community in that she worked and/or attended college classes throughout the period in question. In addition, there is no evidence that the appellant experienced totally incapacitating psychoneurotic symptoms bordering on gross repudiation of reality with disturbed thought or behavioral processes (such as fantasy, confusion, panic, and explosions of aggressive energy) associated with almost all daily activities resulting in a profound retreat from mature behavior. Furthermore, the appellant was able to obtain and retain employment during this period. As for the current regulation, a total occupational and social impairment was not shown at any time between November 7, 1996 and March 14, 1997, and the appellant herself has not reported such total incapacitation. Indeed, the clinical evidence of record does not demonstrate that the appellant ever experienced gross impairment in thought processes or communication or persistent delusions or hallucinations. There were no findings of grossly inappropriate behavior or of any persistent danger of hurting herself or others. There is no evidence of record to indicate that the appellant ever had an intermittent inability to perform her activities of daily living (including maintenance of minimal personal hygiene). She was always described as oriented to time and place and there is no mention of any memory loss for the names of her close relatives, her own occupation, or her own name. Therefore a 70 percent evaluation, but no more, is warranted under the applicable rating criteria for the period from May 22, 1991 to March 14, 1997. However, the evidence of record indicates that the appellant became unable to work due to PTSD symptoms as of March 15, 1997. Therefore, the Board finds, after giving the Veteran the benefit of the doubt, that a 100 percent evaluation is warranted as of March 15, 1997. See Johnson v. Brown, 7 Vet. App. 95 (1994). In addition, there is no indication in the evidence of record that the appellant ever regained her capacity to work. For example, in May 2004, VA vocational rehabilitation services were denied because the appellant's employment was not reasonably feasible. In August 2006, a VA psychiatric examiner stated that it would be very difficult for the appellant to maintain employment. Furthermore, the appellant continues to receive SSA disability benefits. In exceptional cases where schedular evaluations are found to be inadequate, consideration of "an extra-schedular evaluation commensurate with the average earning capacity impairment due exclusively to the service-connected disability or disabilities" is made. 38 C.F.R. § 3.321(b)(1). The governing norm in these exceptional cases is a finding that the case presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization as to render impractical the application of the regular schedular standards. The Board acknowledges that the appellant, in advancing this appeal, believes that her PTSD has been more severe than the previously assigned disability ratings reflected. But there are no clinical findings congruent with the next higher evaluation of 100% prior to March 15, 1997. Medical evidence is generally required to probatively address questions requiring medical expertise; lay assertions do not constitute competent medical evidence for these purposes. Espiritu v. Derwinski, 2 Vet. App. 492, 494(1992). Lay assertions may serve to support a claim by supporting the occurrence of lay-observable events or the presence of symptoms of disability subject to lay observation. 38 U.S.C.A. § 1153(a); 38 C.F.R. § 3.303(a); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); see Buchanan v. Nicholson, 451 F.3d 1331, 1336 (Fed. Cir. 2006) (lay evidence is potentially competent to support presence of disability even where not corroborated by contemporaneous medical evidence). Competency of evidence differs from weight and credibility. The former is a legal concept determining whether testimony may be heard and considered by the trier of fact, while the latter is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted. Rucker v. Brown, 10 Vet. App. 67, 74 (1997); Layno v. Brown, 6 Vet. App. 465, 469 (1994); see also Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991) ("although interest may affect the credibility of testimony, it does not affect competency to testify"). In this case, the appellant is competent to report symptoms because this requires only personal knowledge as it comes to her through his senses. Layno, 6 Vet. App. at 470. In fact, the grants of the initial 70 percent evaluation followed by an increase to a 100 percent evaluation on March 15, 1997, are based in large part on the reports of the appellant and various third parties about her PTSD symptomatology. Neither, however, is competent to identify a specific level of disability of PTSD disability according to the appropriate diagnostic code. See Robinson v. Shinseki, 557 F.3d 1355 (2009). Such competent evidence concerning the nature and extent of the appellant's PTSD disability has been provided by the medical personnel who have examined her during the current appeal and who have rendered pertinent opinions in conjunction with the evaluations. The medical findings (as provided in the examination reports and therapy notes) directly address the criteria under which psychiatric disabilities are evaluated. The Board has carefully considered the appellant's contentions and arguments and awarded higher evaluations in response. In this case, however, the competent medical evidence offering detailed descriptions of the PTSD symptoms and specialized determinations pertinent to the rating criteria are the most probative evidence with regard to evaluating whether a 100 percent rating is warranted prior to March 15, 1997. The lay statements have been considered together with the probative medical evidence clinically evaluating the severity of the PTSD-related symptoms. The preponderance of the most probative evidence does not support assignment of any higher rating than the two assigned herein. Notwithstanding the above discussion, increased evaluations for the PTSD disability could be granted if it were demonstrated that that particular disability presented such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization as to render impractical the application of the regular schedular standards. See 38 C.F.R. § 3.321(b)(1). Given the appellant's complaints, the Board has considered whether this case should be referred to the Director of the VA Compensation and Pension Service for extraschedular consideration under 38 C.F.R. § 3.321(b)(1). See Barringer v. Peake, 22 Vet. App. 242 (2008). The Court has clarified the analytical steps necessary to determine whether referral for extraschedular consideration is warranted. See Thun v. Peake, 22 Vet. App. 111 (2008). First, there must be a comparison between the level of severity and symptomatology of a veteran's service-connected disability and the established criteria found in the rating schedule to determine whether the veteran's disability picture is adequately contemplated by the rating schedule. Id. If not, the second step is to determine whether the claimant's exceptional disability picture exhibits other related factors identified in the regulations as "governing norms." Id.; see also 38 C.F.R. § 3.321(b)(1) (governing norms include marked interference with employment and frequent periods of hospitalization). If the factors of step two are found to exist, the third step is to refer the case to the Under Secretary for Benefits or the Director of Compensation Service for a determination whether, to accord justice, the claimant's disability picture requires the assignment of an extraschedular rating. Id. Here, the symptoms associated with the appellant's service-connected PTSD included depressed mood; anxiety; crying spells; nightmares; some suicidal ideation; difficulty concentrating; explosive anger; impairment of memory; impaired judgment; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships; impaired impulse control (such as unprovoked irritability with periods of violence); difficulty in adapting to stressful circumstances (including work or a worklike setting); and inability to work. The Board finds that the Veteran has not described exceptional or unusual features associated with her PTSD. Clearly the appellant's symptoms cause impairment in her functioning and capacity. However, the extent of her impairment is adequately contemplated by the rating criteria, which reasonably describe the effects of her disability. Therefore, the Board finds that the rating criteria reasonably describe the appellant's disability levels and symptomatology for her service-connected PTSD. As such, the Board finds that the rating schedule is adequate to evaluate the appellant's disability picture. Consequently, the Board concludes that referral of this case for consideration of an extra-schedular rating is not warranted. Thun, 22 Vet. App. at 115-16; Bagwell v. Brown, 9 Vet. App. 337, 338-39 (1996); Floyd v. Brown, 9 Vet. App. 88, 96 (1996). Further, the Board notes that under Johnson v. McDonald, 762 F.3d 1362 (Fed. Cir. 2014), a veteran may be awarded an extraschedular rating based upon the combined effect of multiple conditions in an exceptional circumstance where the evaluation of the individual conditions fails to capture all the service-connected disabilities experienced. However, in this case, there are no additional symptoms that have not been attributed to a specific service-connected disability. Accordingly, this is not an exceptional circumstance in which extraschedular consideration may be required to compensate a claimant for a disability that can be attributed only to the combined effect of multiple conditions. Thus, referral for assignment of an extraschedular evaluation in this case is not in order. Floyd v. Brown, 9 Vet. App. 88, 95 (1996); Bagwell v. Brown, 9 Vet. App. 337 (1996). The preponderance of the most probative evidence is against the assignment of any higher ratings for the service-connected PTSD. The findings needed for an evaluation in excess of 70 percent for the PTSD were not demonstrated prior to March 15, 1997, and a 100 percent evaluation has been assigned from that date until the present time. Since the preponderance of the evidence is against an allowance of an evaluation in excess of 70 percent for the service-connected PTSD prior to March 15, 1997, the benefit-of-the-doubt doctrine is inapplicable. 38 U.S.C.A. § 5107(b). Fagan v. Shinseki, 573 F.3d 1282, 1287 (Fed. Cir. 2009); Ortiz v. Principi, 274 F.3d 1361 (Fed. Cir. 2001). In light of the holding of the Court in Hart, the Board has considered whether the appellant is entitled to a "staged" rating for her PTSD. As reflected in the decision above, the Board has not found any additional variation in her symptomatology or clinical findings that would warrant the assignment of any other staged rating for the PTSD since service connection was granted or since a second tier was assigned. Based upon the record, the Board finds that at no time during the claim/appellate period has the PTSD claim on appeal been more disabling than as currently rated (70 percent prior to March 15, 1997, and 100 percent thereafter). B. SMC VA has a "well-established" duty to maximize a claimant's benefits. See Buie v. Shinseki, 24 Vet. App. 242, 250 (2011); AB v. Brown, 6 Vet. App. 35, 38 (1993); see also Bradley v. Peake, 22 Vet. App. 280 (2008) (finding that SMC "benefits are to be accorded when a veteran becomes eligible without need for a separate claim" and remanding, pursuant to VA's duty to maximize benefits, for VA to determine whether the veteran's posttraumatic stress disorder, rated 70 percent disabling, would entitle her to a TDIU and, therefore, to SMC). Special monthly compensation is payable where a veteran has a single service-connected disability rated as 100 percent and (1) has additional service-connected disability or disabilities independently ratable at 60 percent, separate and distinct from the 100 percent service-connected disability and involving different anatomical segments or bodily systems, or (2) is permanently housebound by reason of service-connected disability or disabilities. This requirement is met when a veteran is substantially confined as a direct result of service-connected disabilities to his or her dwelling and the immediate premises or, if institutionalized, to the ward or clinical areas and it is reasonably certain that the disability or disabilities and resultant confinement will continue throughout his or her lifetime. 38 U.S.C.A. § 1114(s); 38 C.F.R. § 3.350(i). Subsection 1114(s) requires that a disabled veteran whose disability level is determined by the ratings schedule must have at least one disability that is rated at 100 percent in order to qualify for the special monthly compensation provided by that statute. Under the law, subsection 1114(s) benefits are not available to a veteran whose 100 percent disability rating is based on multiple disabilities, none of which is rated at 100 percent disabling. The Court has held that although a TDIU may satisfy the "rated as total" element of section 1114(s), a TDIU based on multiple underlying disabilities cannot satisfy the section 1114(s) requirement of "a service-connected disability" because that requirement must be met by a single disability. In this case, the Board has awarded the appellant a 100 percent evaluation based solely due to her PTSD as of March 15, 1997. Because the appellant had a single service-connected disability rated as total (i.e. her PTSD) as of March 15, 1997, and had additional service-connected disabilities that were independently rated at least 60 percent on March 15, 1997 (i.e. her headaches (50%); costochondritis (10%); and joint pain (10%)), the criteria for SMC at the housebound rate were met as of March 15, 1997 (the date of entitlement to a 100 percent evaluation for PTSD). Thus, in light of the Court's decisions in Bradley and in Buie, entitlement to SMC at the housebound rate under 38 U.S.C.A. § 1114(s) is granted, effective March 15, 1997. C. TDIU As a 100 percent ("total") schedular rating for PTSD based on a finding of total occupational impairment due to PTSD has been assigned effective March 15, 1997, and as SMC has been assigned as of that same date, the issue of entitlement to a TDIU is rendered moot as of March 15, 1997. However, the period prior to March 15, 1997 remains on appeal, as it is part and parcel with the claim for an initial increased evaluation for the service-connected PTSD. Rice v. Shinseki, 22 Vet. App. 447, 453-54 (2009). Turning to the period between May 22,1991 and March 14, 1997, VA will grant a total disability rating for individual unemployability (TDIU) when the evidence shows that a veteran is precluded, by reason of her service-connected disability, from obtaining and maintaining substantially gainful employment consistent with her education and occupational experience. 38 C.F.R. §§ 3.340, 3.341, 4.16. TDIU benefits are granted only when it is established that the service-connected disability is so severe, standing alone, as to prevent the retention of substantially gainful employment. 38 C.F.R. § 4.16(a). The relevant issue is not whether the veteran is unemployed or has difficulty obtaining employment, but whether the veteran can perform the physical and mental acts required by employment. Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993). Advancing age, any impairment caused by conditions that are not service-connected and prior unemployability status must be disregarded when determining whether a veteran currently is unemployable. 38 C.F.R. § 4.16(a). In determining whether unemployability exists, consideration may be given to the veteran's level of education, special training, and previous work experience, but it may not be given to her age or to any impairment caused by nonservice-connected disabilities. 38 C.F.R. §§ 3.341, 4.16, 4.19. A total disability rating may be assigned, where the schedular rating is less than total, where, if there is only one disability, the disability is rated at 60 percent or more, or where, if there are two or more disabilities, at least one disability is rated 40 percent or more and there is sufficient additional disability to bring the combined rating to 70 percent or more. 38 C.F.R. § 4.16(a). In this case, between May 22, 1991 and March 14, 1997, the appellant had been granted service connection for PTSD, and, as a result of the decision discussed above, that disability was assigned a 70 percent evaluation. Thus, the PTSD rating alone since May 22, 1991 has been 70 percent or more. Therefore, based on the PTSD disability alone, the aforementioned TDIU requirement of one disability rated 60 percent or more has been met at throughout the appeal period. The only question remaining is whether there is evidence that the appellant was unable to secure and maintain substantially gainful occupation as the result of her service-connected PTSD during the period from May 22, 1991 to March 14, 1997. Marginal employment shall not be considered substantially gainful employment, and generally shall be deemed to exist when a veteran's earned income does not exceed the amount established by the U.S. Department of Commerce, Bureau of the Census, as the poverty threshold for one person. Marginal employment may also be held to exist, on a facts-found basis (includes but is not limited to employment in a protected environment such as a family business or sheltered workshop), when earned annual income exceeds the poverty threshold. Consideration shall be given in all claims to the nature of the employment and the reason for termination. 38 C.F.R. § 4.16(a). The Board notes that, for an individual under the age of 65, the poverty threshold was $7,086 in 1991; $7,299 in 1992; $7,518 in 1993; $7,710 in 1994; $7,929 in 1995; $8,163 in 1996; and $8,350 in 1997. The appellant has presented statements that she had been incapable of working due to her service-connected PTSD since May 1991. During her September 1991 VA psychiatric examination, she said that she was working two days per week as a nursing assistant and that she was going to college. A November 1992 VA hospital record reflects that the appellant reported that she was taking college courses and that she worked 15 hours per week. During the August 1993 VA psychiatric examination, the appellant reported that she continued to work 16 hours per week and was taking college courses. An October 1995 VA Form 21-0516-1, indicates that the appellant had received $16,000 in wages between July 1994 and July 1995. A notice letter sent by the RO that same month informed the appellant that she had been denied nonservice-connected pension benefits because her income exceeded the maximum allowable rate of $8,037.00 for a single veteran with no dependents. The appellant submitted a VA Form 526 in November 1995; she stated that she had last worked in October 1995. The appellant stated that her previous job had lasted for 24 months - thus, from October 1993 to October 1995. In March 1996, the appellant submitted an application for VA vocational rehabilitation services (VA Form 28-1900). That application was denied in May 1996, based on a determination that the appellant had no serious employment handicap. The appellant reported working one day per week as a health care aide during a VA neurology examination conducted in December 1996. During a psychological evaluation for SSA purposes in October 1997, the appellant reported that she had worked at a home care entity one or two days per week from 1991 to 1994. Between 1994 and 1995, she said that she had worked fulltime in an outpatient drug rehabilitation center. In a VA Form 527 (Net Worth and Employment) submitted by the appellant in November 1997, she stated that she had become totally disabled in January 1997. She reported that she had earned $24,000 between 1993 and 1994 while working as a secretary. The appellant also reported that she had worked as a rural carrier for the post office from January 1997 to March 1997, and that she earned $12.00 per hour. She said that her last day of work had been March 27, 1997. In her October 1998 application for TDIU (VA Form 8940), the appellant reported that the date her disability had affected her fulltime employment was January 1995. She said that she had last worked fulltime in December 1994, and that she had become too disabled to work in December 1994. She also stated that she had earned $24,000 in 1994 working as an office manager. The appellant also reported that she had worked for the post office as a rural carrier for 20 to 30 hours per week from October 1994 to June 1995, and that she had earned up to $1,500 per month. The December 1998 SSA VLJ decision states that the appellant was found to be disabled by reason of an inability to engage in substantial gainful activity (SGA). The appellant was determined to be disabled for SSA purposes on March 15, 1997; the appellant was described as not having engaged in SGA since that date due to her psychiatric symptomatology. Based on the evidence presented, the Board finds that the preponderance of the evidence is against the claim for a total disability evaluation based on individual unemployability due to the service-connected PTSD alone prior to March 15, 1997. The term "unemployability," as used in VA regulations governing total disability ratings, is synonymous with an inability to secure and follow a substantially gainful occupation. See VAOPGCPREC 75-91 (Dec. 17, 1991). The issue is whether the Veteran's service-connected disability or disabilities precluded her from engaging in substantially gainful employment (i.e., work which is more than marginal, that permits the individual to earn a "living wage"). See Moore v. Derwinski, 1 Vet. App. 356 (1991). In a claim for TDIU, the Board may not reject the claim without producing evidence, as distinguished from mere conjecture, that a veteran's service-connected disability or disabilities do not prevent him or her from performing work that would produce sufficient income to be other than marginal. Friscia v. Brown, 7 Vet. App. 294 (1995), citing Beaty v. Brown, 6 Vet. App. 532, 537 (1994). Here the appellant was shown to have made at least more than the poverty level for the years she worked fulltime as an office manager from 1993 to 1995. In addition, she was earning approximately $1500 per month when she worked for the post office for a six-month period and she was earning $12 per hour between January 1997 and March 1997. Furthermore, for most of the periods where the appellant was working part-time, she was concurrently attending school. Thus, the evidence of record tends to show the appellant was capable of performing the physical and mental acts required by employment for the period between May 22, 1991 and March 14, 1997. For these reasons, the Board finds the preponderance of the evidence is against the claim for a TDIU rating due to the service-connected PTSD prior to March 15, 1997. Consequently, the claim must be denied. In reaching this conclusion, the Board has considered the applicability of the benefit of the doubt doctrine. However, as the preponderance of the evidence is against the Veteran's claim, that doctrine is not applicable in the instant appeal. See 38 U.S.C.A. § 5107(b) (West 2014); Ortiz v. Principi, 274 F.3d 1361, 1364 (Fed. Cir. 2001); Gilbert v. Derwinski, 1 Vet. App. 49, 55-56 (1990). . ORDER An initial disability evaluation of 70 percent, but no more, for PTSD is granted, effective May 22, 1991, subject to the laws and regulations for the payment of benefits. A disability evaluation of 100 percent is granted, effective March 15, 1997, subject to the laws and regulations for the payment of benefits. Special monthly compensation at the housebound rate under 38 U.S.C.A. § 1114(s) is granted, effective March 15, 1997, subject to the law and regulations governing the award of monetary benefits. A total disability rating for individual unemployability due to the service-connected PTSD prior to March 15, 1997 is denied. REMAND A determination has been made that additional development is necessary with respect to the remaining issues on appeal. Accordingly, further appellate consideration will be deferred and this case remanded for action as described below. The United States Court of Appeals for Veterans Claims (Court) has held that a remand by the Court or the Board confers on the veteran or other claimant, as a matter of law, the right to compliance with the remand orders. Stegall v. West, 11 Vet. App. 268 (1998). As noted in the July 2014 Board remand, the Board granted the Veteran's claim of entitlement to service connection for headaches in a decision issued in June 2009. In a June 2010 rating decision, the AMC implemented that grant of service connection for headaches and assigned an initial 10 percent rating, effective August 31, 2004. In May 2011 - within one year of the June 2010 rating decision - the Veteran stated that she did not agree with the August 2004 effective date. Where a claimant files a notice of disagreement (NOD) and the RO has not issued a statement of the case (SOC), the issue must be remanded to the RO for an SOC. See Manlincon v. West, 12 Vet. App. 238, 240-241 (1999). As no SOC had been issued, the Board remanded that claim in July 2014, for issuance of an SOC. In her May 2011 NOD, the appellant had contended that she was entitled to an effective date of May 22, 1991, for the grant of service connection for headaches. While the case was in remand status, the RO, in a June 2015 rating decision, assigned an initial evaluation of 50 percent (the maximum schedular rating for headaches), effective from September 7, 1995. The RO stated that this was the earliest possible effective date because it determined that the appellant had withdrawn her claim for service connection for headaches in March 1993. The RO further stated that this was considered a full grant of benefits. The RO did not thereafter issue an SOC on the issue of entitlement to an earlier effective date for the grant of service connection for headaches. However, as similarly noted in a November 1998 letter from the attorney who was representing the Veteran at the time, while the RO had stated (in a June 1993 letter) that the claim for service connection for PTSD had been withdrawn, it had not been withdrawn. The Board notes that the Veteran had pursued her service connection claim for headaches in tandem with her service connection claim for a psychiatric disorder. Review of the evidence of record reflects that the Veteran had continually prosecuted the headaches claim since her initial claim for benefits was filed in August 1991. In addition, as stated in the December 1992 supplemental statement of the case (SSOC), the Veteran submitted a timely substantive appeal in March 1993; the first sentence of the Veteran's contentions in her substantive appeal says that she was still suffering with migraine headaches that would not go away because of tension. Furthermore, as reflected by the transcript of the personal hearing conducted at the RO on May 12, 1993, the Veteran did not withdraw the issues of entitlement to service connection for headaches and PTSD, but rather reframed the issues as one of entitlement to service connection for a psychiatric disorder with headaches. See Hearing Transcript pp. 2-3. Thus, the matter of entitlement to an effective date earlier than September 7, 1995, for the grant of service connection for headaches is still on appeal. Because the AOJ did not subsequently issue an SOC addressing that earlier effective date issue, the Board must again remand the matter for issuance of an SOC. Manlincon v. West, 12 Vet. App. 238 (1999). To ensure that VA has met its duty to assist in developing the facts pertinent to the claims on appeal and to afford full procedural due process, the case is REMANDED for the following: 1. Ensure that all notification and development action required by statutes, regulations, and any applicable legal precedents has been completed. 2. Examine the Veteran's claim of entitlement to an earlier effective date than September 7, 1995, for the grant of service connection for headaches. If no additional development is required, prepare an SOC in accordance with 38 C.F.R. § 19.29, unless the matter is resolved by granting the benefit sought, or by the Veteran's withdrawal of the NOD. 3. If, and only if, the Veteran files a timely substantive appeal, should the headaches earlier effective date issue be returned to the Board. The appellant has the right to submit additional evidence and argument on the matter the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). Thereafter, the case should be returned to the Board, if in order. The Board intimates no opinion as to the ultimate outcome of this case. The appellant need take no action unless otherwise notified. This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West 2014). ______________________________________________ WAYNE M. BRAEUER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs